Book/Report

Patients face risks when undergoing invasive procedures. This report provides recommendations developed by multidisciplinary consensus and outlines how organizations can implement the standards to improve safety of invasive procedures.

Journal Article > Study

Obstetricians and labor nurses who were given a best practices guideline performed better in a standardized disclosure-and-apology discussion simulation than colleagues who were provided as much time as they thought was needed to prepare. Similar cognitive aids may help clinicians faced with disclosing adverse events to patients.

Journal Article > Study

In 2010, The Joint Commission created accountability measures, evidence-based practices that produce positive impacts on patient outcomes. Each year, The Joint Commission recognizes Top Performers that provide more than 95% of their patients with recommended therapies for at least 3 accountability metrics. This article details Johns Hopkins Hospital's efforts to exceed the Top Performer award thresholds on multiple core measures. To realize this goal, the group developed a conceptual model that addresses the challenges accompanying quality and safety interventions. They also employed the Lean framework of define-measure-analyze-improve-control to help teams systematically create improvement plans. In addition, a monthly performance dashboard provided transparency and accountability. These efforts led to Johns Hopkins Hospital achieving a compliance goal of 96% or higher on 95% of the core measures in 2012. A previous AHRQ WebM&M interview with Dr. Peter Pronovost, the lead author of this paper, discussed the science of improving patient safety.

Journal Article > Study

This study assessed a representative group of hospitals to evaluate their perception and priority of each of the National Quality Forum's (NQF) 30 "safe practices." Investigators analyzed responses from 100 hospitals and determined higher ratings for priority than for progress of the practices overall. They noted the largest discrepancy between priority and progress in creating a safety culture with the highest progress rating for increasing safe medication use. Based on evaluating individual hospital characteristics, the authors also identified 20 safe practices not associated with measures of hospital structure, capacity, or resources. These particular findings may guide other organizations trying to develop strategic safety plans with respect to NQF safety recommendations.

Book/Report

The authors review the ethical foundations of safety in the aviation, health care, and occupational and environmental health industries. The authors encourage professionals to embrace ethical decision making in supporting their safety work.

Newspaper/Magazine Article

This is an alert from the Institute for Safe Medication Practices informing readers of a fatal medication error that occurred because of a misinterpreted decimal point. The error involved administration of morphine to a 9-month-old infant who received 5 mg instead of 0.5 mg of the drug. The order did not include a zero before the decimal point, and the nurse filling the order overlooked the omission. The child suffered a cardiac arrest and died. The case illustrates the importance of clearly communicating information about medications.

Cases & Commentaries

Admitted to the hospital for treatment of a hip fracture, an elderly woman with end-stage dementia was placed on the hospice service for comfort care. The physician ordered a morphine drip for better pain control. The nurse placed the normal saline, but not the morphine drip, on a pump. Due to the mistaken setup, the morphine flowed into the patient at uncontrolled rate.

Unintended consequences associated with usability of electronic health record (EHR) systems have the potential to negatively affect patient safety. This report outlines standards to enhance safety-related usability of EHRs by identifying root causes of use errors and addressing these weaknesses through human factors design.

Audiovisual > Audiovisual Presentation

Hospitals and health systems face challenges in implementing electronic health records that can affect safety. This webinar introduced the SAFER guides, which highlight strategies to improve safety related to electronic health record use, and educate participants about ways to implement these guides in their organizations. The session featured Hardeep Singh and Dean F. Sittig as speakers.

Standard operating procedures, or SOPs, are a key tenet of human factors engineering. This time-series analysis found that implementing SOPs in the operating room did not change either surgical process outcomes, such as adherence to the WHO surgical checklist, or clinical outcomes. These results emphasize the challenge of applying systems solutions in clinical settings.

This quality improvement study found that adherence to patient safety measures while providing radiation therapy—such as verifying patient identification—increased when work processes were standardized. This finding echoes prior work in applying human factors principles to health care.